Association Between Youth-Focused Firearm Laws and Youth SuicidesFREE

Author Affiliations: Center for the Prevention of Youth Violence (Dr Webster and Mr Vernick and Ms Zeoli) and Center for Gun Policy and Research (Dr Webster and Mr Vernick), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; Annenberg Public Policy Center, University of Pennsylvania, Philadelphia (Dr Manganello).

ABSTRACT

Context Firearms are used in approximately half of all youth suicides. Many
state and federal laws include age-specific restrictions on the purchase,
possession, or storage of firearms; however, the association between these
laws and suicides among youth has not been carefully examined.

Objective To evaluate the association between youth-focused firearm laws and suicides
among youth.

Design, Setting, and Participants Quasi-experimental design with annual state-level data on suicide rates
among US youth aged 14 through 20 years, for the period 1976-2001. Negative
binomial regression models were used to estimate the association between state
and federal youth-focused firearm laws mandating a minimum age for the purchase
or possession of handguns and state child access prevention (CAP) laws requiring
safe storage of firearms on suicide rates among youth.

Main Outcome Measures Association between youth-focused state and federal firearm laws and
rates of firearm, nonfirearm, and total suicides among US youth aged 14 to
17 and 18 through 20 years.

Results There were 63 954 suicides among youth aged 14 through 20 years
during the 1976-2001 study period, 39 655 (62%) of which were committed
with firearms. Minimum purchase-age and possession-age laws were not associated
with statistically significant reductions in suicide rates among youth aged
14 through 20 years. State CAP laws were associated with an 8.3% decrease
(rate ratio [RR], 0.92; 95% confidence interval [CI], 0.86-0.98) in suicide
rates among 14- to 17-year-olds. The annual rate of suicide in this age group
in states with CAP laws was 5.97 per 100 000 population rather than the
projected 6.51. This association was also statistically significant for firearm
suicides (RR, 0.89; 95% CI, 0.83-0.96) but not for nonfirearm suicides (RR,
1.00; 95% CI, 0.91-1.10). CAP laws were also associated with a significant
reduction in suicides among youth aged 18 through 20 years (RR, 0.89; 95%
CI, 0.85-0.93); however, the association was similar for firearm suicides
(RR, 0.87; 95% CI, 0.82-0.92) and nonfirearm suicides (RR, 0.91; 95% CI, 0.85-0.98).

Conclusions There is evidence that CAP laws are associated with a modest reduction
in suicide rates among youth aged 14 to 17 years. As currently implemented,
minimum age restrictions for the purchase and possession of firearms do not
appear to reduce overall rates of suicide among youth.

Figures in this Article

Suicide is the third leading cause of death among youth aged 10 to 19
years in the United States, accounting for 1883 deaths in 2001.1 Firearms
were used in approximately half of suicides within this age group in 2001;
however, as recently as 1994, 7 of every 10 suicides among teenagers involved
firearms.1

Firearms are one of the most lethal methods of self-harm.2 Case-control
studies using community and clinical samples have consistently found that
the presence of firearms in the home substantially increased the risk of adolescent
suicide.3- 7 In
addition, a recent state-level study, using the ratio of firearm suicides
to total suicides as a proxy for the prevalence of gun ownership, found that
suicide rates among teenagers and adults are significantly higher in states
with higher rates of gun ownership.8

Several firearm policies are intended to limit the access that underage
youth have to firearms. Since 1968, federal law has required licensed firearms
dealers to prohibit handgun sales to purchasers younger than 21 years. In
1994, a federal law established 18 years as the minimum legal age for possessing
or purchasing handguns, including sales by gun owners who are not licensed
dealers. Many states have also adopted laws establishing a minimum legal age
for being able to purchase or possess a firearm. Another type of law intended
to keep firearms from youth are gun safe storage laws, often referred to as
child access prevention (CAP) laws. As of 2001, 18 states had some form of
CAP law that makes it a crime to store firearms in a manner that allows them
to be easily accessed by children and adolescents. Most require gun owners
to lock up their guns.

There has been little empirical research on the association between
these youth-focused laws and rates of suicide among youth. Marvel9 examined laws banning the possession of firearms by
juveniles and found no evidence that these laws reduced youth suicides. However,
in that study the outcome examined was suicides among youth aged 15 to 19
years, over half of which involve suicides among 18- and 19-year-olds, an
age group not covered by most of the laws. We are not aware of any other study
that has examined the association between minimum age restrictions for firearm
purchases and firearm suicides among youth. In a study of the association
between the first 12 CAP laws and mortality among youth through 1994, Cummings
et al10 reported that state CAP laws were associated
with a 19% decline in suicides among youth aged 10 to 14 years. This estimate
was not emphasized by the authors, presumably because the upper bound of the
95% confidence interval for the rate ratio was 1.01. Lott and Whitley11 reported no statistically significant association
between CAP laws and suicides among children younger than 15 years or among
youth aged 15 to 19 years. However, their use of Tobit regression to estimate
the laws' effects is vulnerable to bias when data are highly skewed and heteroskedastic,
as is the case for state-level data on youth suicides.12

The study herein seeks to address the gap in research on the effects
of firearm laws specifically designed to reduce the access that children and
youth have to firearms. We examine the association between these laws and
suicides among youth aged 14 through 20 years, an age group at much greater
risk of firearm suicide than the younger groups examined in prior research.

METHODS

Study Design

To estimate the association between youth-focused firearm policies and
suicide, we used a quasi-experimental design and regression analyses (described
below) to contrast changes in rates of suicide among youth in states that
adopted laws to restrict youth access to firearms with rate changes in states
that did not make such changes in their laws, while controlling for potential
confounders. State-level data sets were constructed that included the number
of suicides among youth within each state for the years 1976 through 2001
for the 2 age groups potentially affected by the laws. Youth aged 14 to 17
years were the target group for laws establishing 18 years or younger as a
minimum age for handgun purchase or possession, and for most CAP laws. Youth
aged 18 through 20 years were legally affected by laws that increased the
minimum age for handgun purchase or possession from 18 to 21 years.

Outcome Variables

The outcome variables were the number of total, firearm, and nonfirearm
suicides in each age group targeted by the laws. Death certificate data from
the National Center for Health Statistics were used to identify suicide as
a cause of death (International Classification of Diseases,
Ninth Revision external cause of death codes E950-E95913 and International Classification of Diseases, 10th Revision codes
X60-X84, Y87.0, and U0314).

Firearm Laws

We conducted legal research and consulted existing compilations of state
laws15 to obtain information about the youth-focused
firearm laws of interest: minimum purchase age, minimum possession age, and
CAP laws. When states had minimum-age cutoffs for purchase or possession of
handguns that were different from those for purchase or possession of long
guns, we used the cutoffs for handguns. We also collected information about
other firearm laws, such as handgun licensing requirements (also known as
permit-to-purchase laws), which might affect our outcomes of interest. For
each law, we then determined the date it took effect, and whether there had
been any changes to the law itself during the study period.

Dummy variables were created, set equal to 1 when the law was in effect
for the whole year and equal to 0 when no law was in effect. For laws that
were in effect for only part of a specific year, we set the law variable equal
to 1 in a state-year if the law was in place for at least half of the year
and equal to 0 otherwise. For the few laws that affected one part of our age
groups (eg, age 17 years as the minimum age for firearm purchase), we set
the law variable equal to 1 if the law applied to the majority of youth committing
suicide in the age group and equal to 0 otherwise. The federal law establishing
a minimum legal age for handgun purchase and possession was assumed to affect
only states that, prior to the federal law, either had no minimum-age law
of this type or had a law that established a minimum legal age younger than
18 years.

Statistical Analysis

To derive estimates of the association between the laws and youth suicide,
we used negative binomial regression models and generalized estimating equations
to estimate regression parameters. Negative binomial regression is appropriate
for estimating models for count data that are overdispersed (ie, the variance
is greater than the mean),16 as is the case
with state-level youth suicide data. Likelihood ratio tests rejected the null
hypothesis that the distributions were Poisson. Generalized estimating equations
take into account that the data are correlated, in this case by state and
year, and make appropriate adjustments to standard errors for accurate hypothesis
testing.17 Correlation matrices of model residuals
were examined to identify any clear pattern of autocorrelation; however, no
pattern was evident. Therefore, the models were specified with unstructured
autocorrelation, as is recommended for studies of this type,18 using
the PROCGEN program in SAS version 8.2 (SAS Institute Inc, Cary, NC). Each
model included the natural logarithm of the population as an offset variable
with the coefficient constrained to equal 1. Model coefficients were converted
to rate ratios (RRs) so that effects could be expressed in terms of percentage
changes in suicide rates. We used 2-tailed tests of significance and α≤.05
for rejecting the null hypothesis of no effect.

When statistically significant associations were identified, we assessed
whether an association not attributable to change in the covariates could
be attributable to differential prelaw trends in states that passed the law
vs those that did not pass the law. This was assessed by estimating the effects
for a set of dummy variables representing each of the 5 years just prior to
the passage of the law and each of the first 5 years the law was in place.
We assessed the plausibility that significant changes in suicide rates for
an age group were caused by the law by examining whether statistically significant
associations were specific to suicides using firearms and were not associated
with changes in suicide rates among young persons aged 22 to 24 years, a group
not legally affected by the laws. We also estimated a model that included
only those states that had enacted their laws prior to 1996, providing at
least 6 years of follow-up data. Model fit was assessed by comparing deviance
statistics with their asymptotic χ2 distribution19 and
the Akaike information criterion statistic.20

Other Explanatory Variables

In addition to the firearm law variables, the models included indicator
variables for each state, suicides for a within-state comparison group (individuals
aged 22 to 24 years), per capita beer consumption, percentage of the population
living in rural areas, real income per capita, unemployment rates, percentage
of the adult population with a bachelors degree, percentage of the population
of black race, the ratio of adult firearm suicides to total suicides as a
proxy for the prevalence of gun ownership, and percentage of the population
affiliated with specific religious denominations. The dummy variables for
each state control for baseline differences in youth suicide levels across
the 50 states (the District of Columbia was not included in our study). Because
the state firearm policies of interest target a particular age group, we used
within-state suicide rates among young persons aged 22 to 24 years who were
not targeted by the law to control for difficult-to-measure social factors
(eg, social norms regarding suicide) that influence suicide rates among young
persons in a particular state and year. We used year dummy variables to control
for national trends in suicides among youth but also estimated alternative
models with linear trend parameters when such patterns were clearly evident.

Data on state population of youth aged 14 through 20 years21- 23 and
the percentage of residents living in rural areas were obtained from the US
Census.24 Annual per capita beer consumption
data based on beer sales were obtained from the Alcohol Epidemiologic Data
System of the National Institute of Alcoholism and Alcohol Abuse.25 Data on personal income, unemployment, educational
attainment, and religious affiliation were provided by Markowitz et al,26 who obtained the data from government and private
sources.27- 29

RESULTS

Youth-Focused Firearm Laws

As of 2001, federal law and the laws of 46 states have mandated a minimum
age for the purchase of a handgun, with the age ranging from 14 to 21 years.
Of these, 21 states enacted or changed their law during the study period.
Federal law and the laws of 39 states mandated a minimum possession age, ranging
from 15 to 21 years, with 29 states enacting or changing their law during
the study period. Nearly all of these changes established 18 years as the
minimum age for firearm possession. Only 3 states increased their minimum
legal age for handgun possession to 21 years during the study period. Eighteen
states had CAP laws as of 2001. The maximum age of youth covered by these
CAP laws ranged from 13 to 17 years (Table
1). Only 3 states adopted permit-to-purchase firearms licensing
systems during the study period.

Most law changes restricting the access of youth to firearms went into
effect between 1990 and 1995. The federal law establishing 18 years as the
minimum age for handgun purchase and possession went into effect in 1994.
After Florida implemented the nation's first CAP law in late 1989, 14 more
states followed suit before the end of 1995.

Suicide Trends Among Youth

There were 63 954 suicides among youth aged 14 through 20 years
during the 1976-2001 study period, 39 655 (62%) of which were committed
with firearms. Firearm suicide rates among youth aged 14 to 17 years increased
steadily from 2.6 (per 100 000 population) in 1976 to 5.7 in 1994, and
then declined rapidly to 2.5 in 2001 (Figure
1). There were less-dramatic changes in firearm suicide rates among
youth aged 18 through 20 years, except for a steep decrease from 9.6 in 1994
to 5.9 in 2001. There were no noteworthy trends in rates of nonfirearm suicides
within the 2 age groups.

Figure. Youth Suicide Rates by Method and
Age Group, United States, 1976-2001

Association Between Firearm Laws and Suicides Among Youth Aged 14 to
17 Years

Our regression models for suicides among youth aged 14 to 17 years reveal
no statistically significant association between suicide rates and laws setting
minimum ages for firearm purchase or possession enacted at the state or federal
level (Table 2). State CAP laws
were associated with an 8.3% reduction in suicide rates (RR, 0.92; 95% confidence
interval [CI], 0.86-0.98). In states with CAP laws, the annual suicide rate
for youth aged 14 to 17 years was 5.97 per 100 000 during the period
in which these laws were in effect. Our model estimates that in the absence
of these laws the expected rate would have been 6.51.

Table Graphic Jump LocationTable 2. Association Between Youth-Focused
Firearm Laws and Suicides Among Youth Aged 14 to 17 Years and 18 Through 20
Years

The reduction associated with CAP laws was observed for firearm suicides,
which decreased an estimated 10.8% in response to the introduction of CAP
laws (RR, 0.89; 95% CI, 0.83-0.96). There was no statistically significant
association between CAP laws and nonfirearm suicides among youth aged 14 to
17 years (RR, 1.00; 95% CI, 0.91-1.10). Estimates of the association between
CAP laws and suicides among 14- to 17-year-olds were dependent on how national
suicide trends were modeled. The estimates from the primary model noted above
included separate linear-trend parameters for the 1976-1994 period of increasing
suicide rates and for the 1995-2001 period of a downturn in rates. The trend
parameters in this model were highly significant and, based on Akaike information
criterion statistics, this model fit the data better than did a model that
included year indicator variables. Models that assumed no overall pattern
in youth suicide trends but that controlled for year-to-year fluctuations
nationally with year indicator variables found no statistically significant
association between CAP laws and suicide rates in the group aged 14 to 17
years. CAP law estimates did not vary substantially by whether violators could
be charged with felony crimes or by the maximum age of youth targeted by the
laws (data not shown).

The models used to estimate differences in suicide rates among youth
aged 14 to 17 years in each of the 5 years before and after the adoption of
a CAP law revealed no pattern of unmodeled differences between states with
and those without CAP laws just prior to the adoption of these laws. When
we examined the relationship between the length of time a CAP law was in place
and the effects of the laws, there was also no clear pattern in successive
postlaw year effects on total suicide rates, but the association between CAP
laws and firearm suicide rates for this group was most pronounced for the
first year the law was in effect (RR, 0.89; 95% CI, 0.77-1.02).

There was no statistically significant association between permit-to-purchase
licensing laws and suicide rates among youth aged 14 to 17 years (RR, 1.06;
95% CI, 0.92-1.23). Association between the laws and suicide rates among youth
aged 14 to 17 years were not substantially altered when the suicide rate among
22- to 24-year-olds and other covariates were removed from the model.

Association Between Firearm Laws and Suicides Among Youth Aged 18 Through
20 Years

The model for total suicides among youth aged 18 through 20 years estimated
that state laws that increased the legal age for handgun possession to 21
years during the study period were associated with a 12.9% increase in suicide
rates (RR, 1.13; 95% CI, 1.01-1.27) (Table
2). This effect was not statistically significant, however, either
for firearm suicides (RR, 1.14; 95% CI, 0.98-1.34) or nonfirearm suicides
(RR, 1.07; 95% CI, 0.90-1.27). State laws raising the minimum legal purchase
age to 21 years were associated with a 9.0% decline in rates of firearm suicides
among youth aged 18 through 20 years (RR, 0.91; 95% CI, 0.83-1.00); however,
there was no statistically significant association for overall suicide rates
(RR, 0.97; 95% CI, 0.91-1.05).

COMMENT

After steadily increasing between 1976 and 1994, rates of firearm suicides
among youth have decreased sharply. Although many laws enacted during the
early 1990s were intended to decrease access to firearms by children and youth,
this study found no evidence that minimum-age restrictions for firearm purchase
and possession have reduced suicide rates among the age groups targeted by
the laws.

Our models estimate that 3 state laws that increased the minimum legal
age for handgun possession to 21 years were associated with a 12.9% increase
in total suicide risks among youth ages 18 through 20 years. There are several
reasons, however, to doubt the validity of this estimate, including: (1) firearm
and nonfirearm suicide rates were affected equally; (2) there was no increase
in suicides among 14- to 17-year-olds associated with minimum possession age
laws; (3) it is based on only 3 states, 2 of which adopted the change in the
final 2 years of the study; and (4) the absence of a theory for how an intervention
designed to reduced access to means of suicide could lead to a substantial
increase in suicide rates. Similarly, our findings for permit-to-purchase
licensing laws should be regarded with skepticism since they are based on
just 3 changes in state law occurring during the study period, none of which
involved a very restrictive licensing scheme.

We did find convincing evidence that the 18 CAP laws adopted during
the study period led to an 8.3% reduction in suicide rates among youth aged
14 to 17 years. As would be expected if these reductions were attributable
to reduced access to firearms, the reductions were specific to suicides committed
with firearms and to the age group principally targeted by CAP laws. We found
no association between CAP laws and suicide rates among young persons aged
22 to 24 years. Our estimate of the association between CAP laws and firearm
suicides (−10.8%; 95% CI, −18.4% to −3.7%) among youth aged
14 to 17 years is consistent with, though smaller in magnitude than, the estimate
of Cummings et al10 of the association between
CAP laws and firearm suicides among adolescents younger than 15 years (−19.0%;
95% CI, –34.0% to +1.0%). CAP laws were also associated with statistically
significant declines in suicide rates among those in the group aged 18 through
20 years. However, the statistically significant negative association between
CAP laws and rates of suicide using means other than firearms casts doubt
on any causal connection between the laws and lower suicide rates in this
group of older youth.

Some may question whether the reductions in youth suicides that were
associated with CAP laws in this study might be spurious, since many in the
group aged 14 to 17 years were older than the maximum age required for safe
firearm storage. However, many older youth have younger siblings, relatives,
or friends that may prompt their parents to comply with CAP law requirements.
In addition, CAP laws may encourage gun owners with children young enough
to be covered by the law to adopt safe storage practices that endure even
after their children are beyond the age required for safe firearms storage
under the law. Finally, gun owners simply may not respond to very specific
aspects of a CAP law in order to be in compliance. Instead, CAP laws may increase
awareness and change social norms to encourage gun owners to secure firearms
from underage youth. These interpretations are consistent with our finding
that the ages covered by the CAP law were unrelated to the association between
CAP laws and suicides among youth.

There are several reasons that CAP laws might be more effective than
minimum-age restrictions for firearm purchases and possession in reducing
suicides among youth. First, a large majority of youth who commit or attempt
suicide with a firearm use guns owned by their parents or relatives.30,31 Second, the adopted restrictions
on minimum purchase age did not affect the handgun sales practices required
of licensed firearm dealers. Since 1968, federal law has prohibited licensed
dealers from selling handguns to individuals younger than 21 years. In addition,
there is little mevidence that laws governing sales by those who are not dealers
are vigorously enforced in most states32 (Frattaroli
S, unpublished doctoral dissertation, 1999; on file with the authors).

Thus, it is important to recognize that our study is not a test of the
relationship between firearm availability and risk of suicide among youth.
Our results for minimum purchase-age and possession-age laws suggest that
these laws have not substantially reduced the availability of firearms to
youth at risk for suicide. Therefore, our results are not necessarily inconsistent
with prior research, such as findings from Wintemute et al33 that
adult handgun purchasers were at higher risk for suicide, even 6 years after
purchase. If a youth's risk of suicide were greatest several years after he
or she had acquired a firearm, we may have underestimated the full effect
of these laws. But when we limited the analysis to state laws enacted through
1995—providing at least 6 years of follow-up data for the remaining
45 states—we still identified no significant effects for these laws.

As with prior studies of CAP laws, we were unable to directly measure
whether these laws resulted in actual changes in firearm storage practices.
Nevertheless, our weapon-specific estimates of the effects of CAP laws suggest
that these laws did limit the access that youth have to firearms.

This study does not examine the full range of potential effects of CAP
laws. Lott and Whitley11 report that CAP laws
were associated with increases in rapes (9%) and robberies (10%), presumably
because firearms kept in locked storage are potentially less available for
self-defense. Their findings are questionable because the vast majority of
these crimes take place outside the home34 and
firearms are very rarely used for self-defense.35

Our study also does not consider the potential role that laws restricting
the access of youth to firearms might have in reducing unintentional shootings
or homicides. Two prior studies of the association between CAP laws and deaths
among children younger than 15 years from unintentional shootings, with similar
methods but over different time periods, produced similar estimates of aggregate
effect (−23% and –17%).10,36 However,
one of these studies36 found that the aggregate
benefits were largely driven by a single state law (Florida). Marvel9 found no evidence that laws prohibiting possession
of firearms by juveniles were associated with youth being killed by guns or
with their use of guns to commit homicide.

The reductions in suicides associated with CAP laws are relatively modest
in terms of percentage change. However, because the laws target an important
risk factor, a high-risk group, and a leading cause of death, the public health
significance of the laws is meaningful. Assuming that the observed association
is causal, we estimate that the 18 CAP laws implemented prior to 2002 have
prevented 333 suicides among youth aged 14 to 17 years from the time that
Florida implemented the nation's first CAP law (October 1989) through 2001.
In 2001 alone, we estimate that there were 35 fewer suicides among this group
in the 18 states with CAP laws than would have been expected without the laws.
These benefits have been obtained with very modest levels of publicity and
enforcement. Increased efforts to encourage compliance with CAP laws have
the potential to enhance their effectiveness in preventing deaths and injuries
resulting from unsupervised access of youth to firearms.

Further research is needed to ascertain what factors have contributed
to the recent decline in firearm suicides among youth in the United States.
The timing of the decline is coincident with the adoption of several laws
designed to reduce youth access to firearms, yet the only evidence we found
that these laws are responsible for reductions in suicides among youth was
a modest reduction associated with CAP laws. The passage of many youth-focused
firearm restrictions during the early 1990s may have been associated with
broader changes in those social norms that involve allowing youth access to
firearms—norms that affect states both with and without recent changes
to their firearm laws. If the passage of laws restricting youth access to
firearms influenced norms and practices both within and outside the states
that adopted the laws, our estimates would understate the effect of these
laws on suicide rates among youth.

REFERENCES

Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control. Web-based Injury Statistics and Query Reporting System. Available at: http://www.cdc.gov/ncipc/wisqars. Accessed
December 17, 2003.

US Census Bureau. Intercensal Estimates of the Resident Populations of States 1970 to
1980. US Dept of Commerce, 2002. Available at: http:/eire.census.gov/popest/archives/pre1980/e7080sta.txt.
Accessed October 1, 2003.

US Census Bureau. Historical Annual Time Series of State Population Estimates and Demographic
Components of Change 1980 to 1990, by Single Year of Age and Sex. US Dept of Commerce, 2002. Available at: http:/eire.census.gov/popest/archives/state/st_stig.php.
Accessed October 1, 2003.

US Census Bureau. Population Estimates: 1990 to 1999 Annual Time Series of State Population
Estimates, by Single Year of Age and Sex. US Dept of Commerce, 2002. Available at: http:/eire.census.gov/popest/archives/state/st-99-10.php.
Accessed October 1, 2003.

Jones DE, Doty S, Horsch JE.
et al. Religious Congregations and Membership in the United
States, 2000: An Enumeration by Region, State, and County Based on Data Reported
by 149 Religious Bodies.Nashville, Tenn: Glenmary Research Center; 2002.

References

Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control. Web-based Injury Statistics and Query Reporting System. Available at: http://www.cdc.gov/ncipc/wisqars. Accessed
December 17, 2003.

US Census Bureau. Intercensal Estimates of the Resident Populations of States 1970 to
1980. US Dept of Commerce, 2002. Available at: http:/eire.census.gov/popest/archives/pre1980/e7080sta.txt.
Accessed October 1, 2003.

US Census Bureau. Historical Annual Time Series of State Population Estimates and Demographic
Components of Change 1980 to 1990, by Single Year of Age and Sex. US Dept of Commerce, 2002. Available at: http:/eire.census.gov/popest/archives/state/st_stig.php.
Accessed October 1, 2003.

US Census Bureau. Population Estimates: 1990 to 1999 Annual Time Series of State Population
Estimates, by Single Year of Age and Sex. US Dept of Commerce, 2002. Available at: http:/eire.census.gov/popest/archives/state/st-99-10.php.
Accessed October 1, 2003.

Jones DE, Doty S, Horsch JE.
et al. Religious Congregations and Membership in the United
States, 2000: An Enumeration by Region, State, and County Based on Data Reported
by 149 Religious Bodies.Nashville, Tenn: Glenmary Research Center; 2002.

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